• Spondyloarthritis is a family of inflammatory diseases characterized by pain and stiffness in the spine (especially the low back).
• Subtypes include axial spondyloarthritis (axSpA), which affects the spine and sacroiliac joints, and peripheral spondyloarthritis (pSpA), which affects joints in parts of the body other than the spine, such as the arms and legs.
• Spondyloarthritis often starts in the late teens to mid-20s, but it can take years to get an accurate diagnosis.
• Lifestyle changes, including smoking cessation, good posture, exercise, and diet, are important.
• There is a genetic component to spondyloarthritis, and physicians may use genetic tests to help diagnose it.

Spondyloarthritis is a family of inflammatory rheumatic diseases that causes arthritis. The main symptoms are pain and stiffness in the spine (especially the lower back).¹ It is relatively common, affecting more people than multiple sclerosis, rheumatoid arthritis, or amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease). Still, spondyloarthritis remains relatively unknown to many people — even physicians. One in 100 people in the United States has spondyloarthritis, or about 3.2 million people.²

Spondyloarthritis is a progressive disease. Some people may experience new bone formation in the spine or spinal fusion — which can lead to problems with mobility. There is no cure for spondyloarthritis, but symptoms such as pain, stiffness, and fatigue can be managed.¹

Axial spondyloarthritis (axSpA) is a type of spondyloarthritis that mostly affects the spine and sacroiliac joints — a pair of joints in the pelvis.¹ There are two progressive stages of axial spondyloarthritis:

	Nonradiographic axial spondyloarthritis — Damage to the spine or sacroiliac joints is not visible on X-ray, but it can be seen as inflammation on magnetic resonance imaging (MRI) scans.
	Ankylosing spondylitis (AS or radiographic axial spondyloarthritis) — Damage of the spine or sacroiliac joints is visible on X-ray.3

Not all people living with nonradiographic axSpA will progress to radiographic AS; however, people affected by either stage may have similar levels of pain, stiffness, and fatigue.^3,4

Peripheral spondyloarthritis (pSpA) is a type of spondyloarthritis that affects the joints in parts of the body other than the spine, such as the arms and legs.¹ There are a number of subtypes,⁵ including:

• Reactive arthritis (formerly known as Reiter's syndrome), which arises following an infection⁶
• Psoriatic arthritis, which is associated with the skin condition psoriasis
• Enteropathic arthritis/spondylitis, which is associated with inflammatory bowel diseases (ulcerative colitis and Crohn's disease)
• Undifferentiated spondyloarthritis, which does not meet established definitions for other forms of spondyloarthritis

Common symptoms of spondyloarthritis include:⁷

• Lower back pain and buttock pain
• Morning stiffness which improves with exercise but not with rest
• Fatigue
• Pain that causes sleep disturbances
• Reduced mobility

Add a comment below: Do you have symptoms of spondyloarthritis?

Spondyloarthritis has a genetic component. Family members of those with spondyloarthritis are at higher risk, depending partly on whether they inherited the HLA-B27 gene.1 Having the HLA-B27 gene does not always mean someone will develop spondyloarthritis. In the end, the diagnosis relies on a rheumatologist’s judgment based on several factors considered together.

Spondyloarthritis often starts in the late teens or mid-20s. It can take between 8 and 11 years to get a correct diagnosis.⁸ Lower back pain is a symptom for most people with spondyloarthritis, but this type of pain is also extremely common in the general population.¹ Often, back pain is initially managed by primary care physicians until it becomes severe or a doctor determines you have inflammatory back pain. Inflammatory back pain is different from mechanical back pain — which is caused by structural changes in the joints, vertebrae, or tissue and may be caused by an injury.

For diagnosis, a rheumatologist may order imaging — including an X-ray or MRI of the spine or sacroiliac joints — to look for signs of inflammation or spinal fusion. A doctor may also order blood tests to check for certain genetic markers or proteins.¹ (Take our quiz: Could I Have Spondyloarthritis?)

Living with the chronic back pain of axial spondyloarthritis requires care from a specialist called a rheumatologist. A rheumatologist can help create a treatment plan that may include nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), or biologic treatments.⁷

Lifestyle Changes Lifestyle changes, such as good posture, exercise, and a nutritious diet, may help some people with spondyloarthritis. Stopping smoking is crucial because smoking has been shown to increase spinal disease progression, as well as reduce response to treatment.9 Exercise is particularly important for people with axial spondyloarthritis, including physical therapy and joint-directed exercises.1 Many recommended exercises promote spinal extension and mobility. Learn more about Spondyloarthritis Exercises for Better Posture. The American College of Rheumatology recommends physical therapy for people with ankylosing spondylitis. Active physical therapy with supervised exercises is recommended over massage and similar passive physical therapy. Exercise on land is also preferred over water-based exercise.10 Visiting a chiropractor for a spinal adjustment is not recommended, especially if you have osteoporosis or your spine is fused.11 Add a comment below: What lifestyle changes have made a difference with your spondyloarthritis?

Surgery People with spondyloarthritis may wonder about surgery to treat their condition. Elective spinal surgery is generally not recommended as a treatment. One reason for discouraging elective surgery is the risk associated with the procedure, including the possibility of neurological problems. In a few cases, surgery may be worth the considerable risk. For example, surgery to correct spinal deformities may be appropriate for people whose deformity is so severe they cannot look straight ahead.12 Other surgeries on the joints may be appropriate. Surgery may be recommended for people whose hips are significantly affected. In this case, a total hip replacement may be appropriate.10

Peripheral spondyloarthritis affects joints other than those in the back or pelvis. Inflammatory back pain, such as that experienced with axSpA, is also possible in people with pSpA, but it is generally not the key symptom. Common symptoms of pSpA include:¹³

	Enthesitis — This inflammation where ligaments and tendons connect to bones often presents as swelling at the heels. It can cause pain and tenderness.
	Dactylitis — Also known “sausage toe” or “sausage finger,” this is severe inflammation of tissues in the fingers or toes. While it is uncommon, it is a characteristic feature of pSpA and is often associated with psoriatic arthritis.

Additionally, people with pSpA may have one or more of the following:

• Damage on sacroiliac joints (in the pelvis) visible on X-ray
• Past history of back pain
• Family history of spondyloarthritis or having the HLA-B27 gene, which is associated with spondyloarthritis

People with pSpA may also have conditions that don’t involve the joints, including psoriasis, inflammatory bowel disease, or anterior uveitis.

Spondyloarthritis is associated with certain health conditions. When a person has additional health conditions alongside spondyloarthritis, they are known as comorbidities.

The following conditions are comorbidities in spondyloarthritis.

Cardiovascular Disease

Between 2 percent and 10 percent of people with ankylosing spondylitis have heart problems like hypertension (high blood pressure), arrhythmias (heartbeat that is too fast or slow), and ischemic heart disease.¹⁴

Heart disease is a serious concern, but there are steps you can take to minimize the risk of developing it or to better manage it. Regular exercise, a healthy diet, and quitting smoking if you smoke can help lower your risk of developing heart conditions or help you manage one. Annual screening for cardiovascular disease is also important for monitoring your health.¹⁴

Osteoporosis

About half of people with ankylosing spondylitis also have osteoporosis, particularly those whose spine has fused. Osteoporosis can increase the risk of fractures, including spinal fractures.¹

Screening for osteoporosis is especially important for people with ankylosing spondylitis. Various treatments can be prescribed for people found to have osteoporosis. Weight-bearing exercise and sufficient calcium and vitamin D intake are important for everyone with AS, to reduce the risk of osteoporosis or to help manage it.¹⁵

Uveitis

As many as half of people with spondyloarthritis will develop uveitis (eye inflammation). Uveitis usually occurs in one eye at a time. Symptoms include redness, sensitivity to light, and pain. It’s important to seek medical attention right away to prevent permanent damage to the eyes. Treatment usually consists of corticosteroid eye drops.¹⁶

Psoriasis

Psoriatic arthritis is a type of spondyloarthritis that occurs in about 30 percent of people with psoriasis, a skin condition characterized by scales and plaques.¹⁷ Most people with psoriatic arthritis also have the skin symptoms of psoriasis.¹⁸ There are several treatment options for psoriasis, including topical treatments, oral medications, and biologics.

Inflammatory Bowel Disease

Inflammatory bowel diseases like Crohn’s disease and ulcerative colitis occur in 6 percent to 14 percent of people with ankylosing spondylitis. Some treatments for IBD are not appropriate for people with AS, and some AS treatments are not appropriate for people with IBD. For example, long-term use of NSAIDs is not recommended for people with IBD.¹⁹ Open communication with the health care providers treating your AS and IBD is important to ensure your treatments are appropriate for you. Consider bringing a list of all of your medications to appointments with your doctors.

References

1. Spondyloarthritis. (2019, March). Retrieved December 21, 2020, from https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Spondyloarthritis
2. Spondylitis Association of America - Ankylosing Spondylitis. (2020, November 01). Retrieved December 21, 2020, from https://spondylitis.org/
3. Sieper, J., & Heijde, D. V. (2013). Review: Nonradiographic axial spondyloarthritis: New definition of an old disease? Arthritis & Rheumatism, 65(3), 543-551. doi:10.1002/art.37803
4. What Is Non-Radiographic Axial Spondyloarthritis? (n.d.). Retrieved December 21, 2020, from https://spondylitis.org/spondylitis-plus/what-is-non-radiographic-axial-spondyloarthritis/
5. 6 Types of Spondylitis: What You Need to Know. (n.d.). Retrieved December 21, 2020, from https://spondylitis.org/about-spondylitis/types-of-spondylitis/
6. Reactive Arthritis. (2019, March). Retrieved December 21, 2020, from https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Reactive-Arthritis
7. Spondyloarthritis. (n.d.). Retrieved December 21, 2020, from https://www.arthritis.org/diseases/spondyloarthritis
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9. Taurog, J. D., Chhabra, A., & Colbert, R. A. (2016). Ankylosing Spondylitis and Axial Spondyloarthritis. New England Journal of Medicine, 374(26), 2563-2574. doi:10.1056/nejmra1406182
10. Ward, M. M., Deodhar, A., Gensler, L. S., Dubreuil, M., Yu, D., Khan, M. A., . . . Caplan, L. (2019). 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis & Rheumatology, 71(10), 1599-1613. doi:10.1002/art.41042
11. 2019 Axial Spondyloarthritis Treatment Recommendations: A Brief Overview For Patients And Families (Rep.). (2019). Retrieved December 18, 2020, from Spondylitis Association of America website: https://spondylitis.org/wp-content/uploads/2020/01/SAA_Pocket_Guide_WEB.pdf
12. Ward, M. M., Deodhar, A., Akl, E. A., Lui, A., Ermann, J., Gensler, L. S., . . . Caplan, L. (2015). American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis & Rheumatology, 68(2), 282-298. doi:10.1002/art.39298
13. Rudwaleit, M. (2010). New approaches to diagnosis and classification of axial and peripheral spondyloarthritis. Current Opinion in Rheumatology, 22(4), 375-380. doi:10.1097/bor.0b013e32833ac5cc
14. Cardiovascular Diseases and Spondylitis. (n.d.). Retrieved December 18, 2020, from https://spondylitis.org/about-spondylitis/possible-complications/the-heart-in-spondylitis/
15. Hinze, A. M., & Louie, G. H. (2016). Osteoporosis Management in Ankylosing Spondylitis. Current treatment options in rheumatology, 2(4), 271–282. https://doi.org/10.1007/s40674-016-0055-6
16. Iritis/Anterior Uveitis: Inflammation of the Eye. (n.d.). Retrieved December 18, 2020, from https://spondylitis.org/about-spondylitis/possible-complications/iritis-or-anterior-uveitis/
17. What is Psoriatic Arthritis? (n.d.). Retrieved December 18, 2020, from https://www.psoriasis.org/about-psoriatic-arthritis/
18. Coates, L. C., & Helliwell, P. S. (2017). Psoriatic arthritis: State of the art review. Clinical Medicine, 17(1), 65-70. doi:10.7861/clinmedicine.17-1-65
19. Fragoulis, G. E., Liava, C., Daoussis, D., Akriviadis, E., Garyfallos, A., & Dimitroulas, T. (2019). Inflammatory bowel diseases and spondyloarthropathies: From pathogenesis to treatment. World journal of gastroenterology, 25(18), 2162–2176. https://doi.org/10.3748/wjg.v25.i18.2162